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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH!, .?ARTMENT 304 E' WEBEIK AVE 3"a FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTION'S EXPIRES I YEAR FROM DATE ISSUED "Z— tl ,IOBADDRESS Lr-Ou 5r. - CITYIZIP Y W [27 I! C� PARCEL SIZE z CROSS STREET APN� � OWNER NAME &1 -611` PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR � rC ��/J PHONE 1—�ry"`:17�� r(� CITY/STATEIZIP / CONTRACTOR ADDRESS Y�--+�_.- _._ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP I — �L LICENSE 4-57 ❑C-61 ❑D-09 ❑Other NUMBER'-/67-Z-5"—Z-- EXPIRATION DATE t)� GEOGRAPHICAL INFORMATION: Coordinates X Y Township - Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quafity Monitoring ❑Soil Sampling/Charactenzation ❑Public Water System If different fromOwner: Water System Name Comact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Moditicati ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) Soil Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 3!0 ft Excavation !!� in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941h hag/5-10 gal water) ❑Sand Cement .tack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed_By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased 0 Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 16 hug/5-10 gal water) ❑Sand Cement sack mix/7 gal water Bentonite Pellets IF ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE1FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENS TION LAW MINIM A E OTICE REQUIRED FOUR INSPECTIONS —PLEASE CALL.(209)953-76 7 SIGNED TITLE f��l/V�(�IrGlri�� DATE if ii it h i °a'ir int YL .t r p �Iy�+c,L•T G1� r� ...�„ RtliiMni O N St ,� CIS 1 'rI M fri DEPARTMENT-USE 'O�NLY Application Accepted By t .t v`• Date_ it 1;' Area ! " Employee ID# 1--3 Grout inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspe tion By - Date �d �� Constructed Well Depth ft COMMENTS / 10 0 PE SC Received Chec 1 Amount Date Permit/ Invoice# Well 1D# Codes Info By ash Remitted Service Re uest# 1 ,50 Z.-Z- l[ I23 003-V40 EHD43-02-006 �� ` ,�I MAS•TEKWATER WELL PERMIT 12/6/2002 �'!